Polyaxial bone anchoring device

ABSTRACT

A polyaxial bone anchoring device includes a bone anchoring element having a shank and a head, a head receiving part having a first end, an open second end, and a hollow interior portion for receiving the head therein, a locking ring configured to be mounted around the head receiving part and having a rod receiving portion, a cap configured to be connected to the head receiving part, the cap having a central axis and two opposite legs extending in a direction of the central axis, and a locking element configured to extend from the cap to lock relative positions of the bone anchoring element and an inserted rod relative to the head receiving part, wherein the cap is rotatable relative to the head receiving part between a first position in which the cap is movable and a second position in which the legs engage the head receiving part.

CROSS-REFERENCE TO RELATED APPLICATIONS

The present application is a continuation of U.S. patent applicationSer. No. 13/673,837, filed Nov. 9, 2012, which priority to and thebenefit of U.S. Provisional Patent Application Ser. No. 61/559,326,filed Nov. 14, 2011, the contents of which are hereby incorporated byreference in their entirety, and claims priority to European PatentApplication EP 11 189 042.2, filed Nov. 14, 2011 the contents of whichare hereby incorporated by reference in their entirety.

BACKGROUND

1. Field of the Invention

The invention relates to a polyaxial bone anchoring device including abone anchoring element for anchoring in a bone or a vertebra, a headreceiving part for receiving a head of the bone anchoring element, alocking ring mounted around the head receiving part for coupling astabilization rod to the head receiving part and to the bone anchoringelement, and a cap with a locking element for securing the rod and forlocking the assembly. When the rod is mounted in a rod receiving portionof the locking ring and the cap is placed onto the assembly, the cap isrotatable with respect to the head receiving part between a firstposition in which the cap is out of engagement with the head receivingpart and a second position in which the cap engages the head receivingpart. The locking element exerts pressure onto the rod to move thelocking ring to a position where the locking ring locks the head in thehead receiving part. Simultaneously, the rod can be fixed by the lockingelement.

2. Description of Related Art

US 2009/0149887 A1 describes an apparatus for connecting a bone anchorto a support rod including a connector body, a sleeve around theconnector body and a cap.

US 2011/0213419 A1 describes a screw and rod fixation assembly includinga body member including a screw seat for seating a screw head thereinand a rod seat for seating a rod therein. An adjustable locking ringapplies a locking force against the screw head seated in the screw seatand a locking cap adjustably applies a locking force against a rodseated in the rod seat. The adjustable screw locking ring and lockingcap function independent of each other.

SUMMARY

It is an object of embodiments of the invention to provide a polyaxialbone anchoring device having a wider range of applications, inparticular, being more suitable for applications that require boneanchors with relatively small size.

The polyaxial bone anchoring device makes use of a cap and a lockingelement received in the cap for securing and fixing a rod and a head ofa bone anchoring element. Therefore, a problem of splaying of portionsof a receiving part when tightening the locking element, as known fromconventional bone anchors, does not occur. Furthermore, with the cap,the bone anchoring device can have a lower profile in an axial or heightdirection of the bone anchoring device. This allows the bone anchoringdevice to be particularly suitable for use in the cervical spine or inpediatric applications where smaller bone anchoring devices are desired,trauma, and minimally invasive applications, or for using in other typesof bone surgery.

With the polyaxial bone anchoring device according to embodiments of theinvention, a modular bone anchoring system can be provided. The modularsystem can include a head receiving part preassembled with a lockingring, the cap preassembled with the locking element, and a set ofvarious bone anchoring elements having different shanks. Various shankswith different diameter, thread form, or other different features can becombined with the head receiving part and locking ring according to therequirements of each particular clinical situation. Therefore, a surgeonor other practitioner has a more substantial or wider choice ofimplants. By such modularity, costs of stock-holding can also bedecreased.

BRIEF DESCRIPTION OF THE DRAWINGS

Further features and advantages will become apparent from thedescription of embodiments by means of the accompanying drawings. In thedrawings:

FIG. 1 shown an exploded perspective view of a polyaxial bone anchoringdevice according to a first embodiment;

FIG. 2 shows a perspective view of the polyaxial bone anchoring deviceof FIG. 1 in an assembled state;

FIG. 3 shows a perspective view from a top of a head receiving part ofthe polyaxial bone anchoring device according to the first embodiment;

FIG. 4 shows a perspective view from a bottom of the head receiving partaccording to the first embodiment;

FIG. 5 shows a cross-sectional view of the head receiving part accordingto the first embodiment, where the section has been taken perpendicularto an axis of an inserted rod and slightly offset from a center of thehead receiving part;

FIG. 6 shows a top view of the head receiving part according to thefirst embodiment;

FIG. 7 shows a perspective view from a top of a cap of the polyaxialbone anchoring device according to the first embodiment;

FIG. 8 shows a perspective view from a bottom of the cap according tothe first embodiment;

FIG. 9 shows a side view of the cap according to the first embodiment;

FIG. 10 shows another side view of the cap, rotated by 90° from FIG. 9,according to the first embodiment;

FIG. 11 shows a top view of the cap according to the first embodiment;

FIG. 12 shows a cross-sectional view of the cap according to the firstembodiment, the cross-section taken along line A-A in FIG. 11;

FIG. 13 shows a perspective view of a locking ring of the polyaxial boneanchoring device according to the first embodiment;

FIG. 14 shows a cross-sectional view of the locking ring according tothe first embodiment, the cross-section taken along line B-B in FIG. 13;

FIG. 15 shows a top view of the locking ring according to the firstembodiment;

FIG. 16 a shows a cross-sectional view of an assembled polyaxial boneanchoring device according to the first embodiment, the section beingtaken in a plane perpendicular to the rod axis;

FIG. 16 b shows an enlarged view of a portion of FIG. 16 a;

FIGS. 17 to 22 show steps of assembly and use of the polyaxial boneanchoring device according to the first embodiment;

FIG. 23 shows an exploded perspective view of a polyaxial bone anchoringdevice according to a second embodiment;

FIG. 24 shows a perspective view of the polyaxial bone anchoring deviceaccording to the second embodiment in an assembled state;

FIG. 25 shows a perspective view from a top of a head receiving part ofthe polyaxial bone anchoring device according to the second embodiment;

FIG. 26 shows a perspective view from a bottom of the head receivingpart according to the second embodiment;

FIG. 27 shows a top view of the head receiving part according to thesecond embodiment;

FIG. 28 shows a cross-sectional view of the head receiving partaccording to the second embodiment, the cross-section being taken alongline C-C in FIG. 27;

FIG. 29 shows a perspective view of a top of a cap of the polyaxial boneanchoring device according to the second embodiment;

FIG. 30 shows a perspective view from a bottom of the cap according tothe second embodiment;

FIG. 31 shows a side view of the cap according to the second embodiment;

FIG. 32 shows a side view of the cap of the second embodiment, rotatedby 90° from FIG. 31;

FIG. 33 shows a top view of the cap according to the second embodiment;

FIG. 34 shows a cross-sectional view of the cap according to the secondembodiment, the cross-section being taken along line D-D in FIG. 33;

FIG. 35 shows a side view of the polyaxial bone anchoring deviceaccording to the second embodiment in an assembled state, seen in adirection along the rod axis;

FIG. 36 a shows a cross-sectional view of the polyaxial bone anchoringdevice according to the second embodiment shown in FIG. 35;

FIG. 36 b shows an enlarged view of a portion of FIG. 36 a;

FIGS. 37 a and 37 b show perspective views of a head receiving part of apolyaxial bone anchoring device according to a further alternateembodiment; and

FIGS. 38 a to 38 c show steps of assembly and use of the polyaxial boneanchoring device according to the further alternate embodiment.

DETAILED DESCRIPTION

As shown in FIGS. 1 and 2, a polyaxial bone anchoring device accordingto a first embodiment includes a bone anchoring element 1 in the form ofa bone screw having a shank 2 with a threaded portion and a sphericalsegment-shaped head 3. The head 3 has a recess 4 (see FIG. 16 a) forengagement with a tool. The bone anchoring device further includes ahead receiving part 5 for receiving the head 3 of the bone anchoringelement 1, and a locking ring 6 for receiving a rod 7, for example, aspinal stabilization rod, and for connecting the rod 7 to the boneanchoring element 1. In addition, the bone anchoring device includes acap 8 for securing the rod 7 and a locking element 9 in the form of aset screw for locking the rod 7 and the head 3 relative to the rest ofthe bone anchoring device.

Referring in particular to FIGS. 3 to 6, the head receiving part 5 has afirst end 5 a and an opposite second end 5 b, a central axis C and acoaxial through hole 5 c. At the first end 5 a, the head receiving part5 has a cylindrical portion 50 with an outwardly extending flange or rim51. A cylinder-segment-shaped recess 52 is formed at the first end 5 a.The recess 52 serves as a seat for guiding the rod 7. At both ends ofthe cylinder-segment-shaped recess 52, the rim 51 is flattened,resulting in opposite flat surfaces 52 a, 52 b. At an angle to an axis Lof the recess 52, there are cutouts 53 a, 53 b from the rim 51, so thattwo opposite rim portions 51 a, 51 b extend outward in a radialdirection. The rim portions 51 a, 51 b extend in a circumferentialdirection substantially between the end of the rod guiding recess 52 upto an angle of around 90° relative to the axis L. A base surface of thecutouts 53 a, 53 b is cylindrical (e.g., forming part of cylindricalportion 50). The rim portions 51 a, 51 b each have on their side facingaway from the first end 5 a a circumferentially extending undercutportion 51 c. The undercut portion 51 c is formed by a surface that isinclined outwards and towards the second end 5 b. The undercut portion51 c serves for engagement with a portion of the cap 8. The cylindricalportion 50 continues into a conically-shaped outer surface portion 55widening towards the second end 5 b. Further, an internal hollowspherical section 56 forming an accommodation space and a seat forspherical segment-shaped head 3 of the bone anchoring element 1 isformed in the head receiving part 5. The internal hollow sphericalsection 56 is configured to encompass the head 3 of the bone anchoringelement 1 from the side, covering a region including a largest diameterof the head 3.

A plurality of slits 57 are provided that are open to the second end 5b. The slits 57 extend substantially through the wall of the internalhollow portion 56 and render the head receiving part 5 flexible in aregion where the head 3 is received. By the size and the number of theslits 57, a desired elasticity is provided to the head receiving part 5.The elasticity of the head receiving part 5 is such that the head 3 ofthe bone anchoring element 1 can be inserted by expanding the headreceiving part 5, and can be clamped therein by compressing the headreceiving part 5.

Referring to FIGS. 7 to 12, the cap 8 is a substantially cylindricalpart with a first end 8 a and an opposite second end 8 b. At the firstend 8 a, there is a coaxial threaded through hole 81 for receiving thelocking element 9. A coaxial bore 82 having a greater diameter than thethreaded through hole 81 extends from the second end 8 b to a distancefrom the first end 8 a. The threaded through hole 81 opens into thecoaxial bore 82. At a distance from the second end 8 b, acircumferential groove 83 is provided that has a lower inclined wall. Bymeans of this, the cap 8 has adjacent its second end 8 b an inwardlydirected rim 85 with the inclined wall forming an undercut portion 84.The incline of the undercut portion 84 corresponds substantially to theincline of the undercut portion 51 c of the head receiving part 5.

The cap 8 further has two opposite substantially cuboid or rectangularshaped recesses 86 a, 86 b that extend from the second end 8 b to adistance from the first end 8 a. The recesses 86 a, 86 b may haverounded edges. By means of the recesses 86 a, 86 b, two oppositelongitudinal legs 87 a, 87 b are formed in the lower portion of the cap8. The recesses 86 a, 86 b have such a height and width that the cap 8is configured to cover the rod 7 when the rod 7 is mounted to the headreceiving part 5 and the locking ring 6. Further, the recesses 86 a, 86b have a width in a circumferential direction that is substantiallygreater than a diameter of the rod 7, so that the legs 87 a, 87 b areconfigured to fit into a space between the locking ring 6 and the rimportions 51 a, 51 b, at positions of the cutouts 53 a, 53 b. In otherwords, the legs 87 a, 87 b have a width in a circumferential directionthat is smaller or equal to the width of the cutouts 53 a, 53 b of thehead receiving part 5.

The locking element 9 in the form of a set screw is configured to bescrewed into the threaded through hole 81. Although the thread of thecap 8 is shown to be a flat thread, any other thread form, such as ametric thread, can be used.

Referring to FIGS. 13 to 16 b, the locking ring 6 has a ring portion 60with a first end 6 a and an opposite second end 6 b. An outer surface ofthe ring portion 60 may be slightly conical, tapering towards the second6 b, to reduce a size of the bone anchoring device in a radialdirection. The ring portion 60 has a curved internal surface portion 62,wherein the curvature is directed towards a center of the locking ring6. The curved surface portion 62 can have a cross-section having acircular curvature, but other types of curvatures are also possible. Aninner diameter of the locking ring 6 is such that the locking ring 6 canslide along the outer conical surface portion 55 of the head receivingpart 5, thereby compressing the head receiving part 5 increasingly whensliding downwards (e.g., towards second end 5 b).

At the first end 6 a, the locking ring 6 includes two projections 63located diametrically opposite to each other. The projections 63 have aheight such that they project up and away from the first end 5 a of thehead receiving part 5 when the locking ring 6 is mounted around the headreceiving part 5, as depicted, for example, in FIG. 18. At their freeends, the projections 63 each have a recess 64 that has a shape of asegment of a circle including at least a portion with a greatestdiameter of said circle. The diameter of the circular segment-shapedrecess 64 corresponds substantially to the diameter of the rod 7. Bymeans of the recess 64, each projection 63 has two upstanding legs 63 a,63 b, that allow the rod 7 to be caught or held therein. As seen inFIGS. 13 and 15, a side 63 c of the projections 63 that faces a centralaxis of the ring 6 may be flat.

The locking ring 6 may further include, at a position of the projections63, on an inside of the locking ring 6 at the first end 6 a two inwardlyprojecting surfaces 65. The surfaces 65 may act as stops, for example,for cap 8 when the bone anchoring device is assembled.

The flexibility of the head receiving part 5 and a size of the headreceiving part 5 at the open second end 5 b allows mounting of thelocking ring 6 from the second end 5 b. When the locking ring 6 ismounted onto the head receiving part 5, the locking ring 6 is preventedfrom rotation around the head receiving part 5 due to the flat surfaces52 a, 52 b of the head receiving part 5 facing and engaging the flatsides 63 c of the projections 63. Dimensions of the respective parts canbe designed such that the head 3 is preliminarily held in the headreceiving part 5 by a slight friction force, and the locking ring 6 canalso be held by a friction force in a preliminary manner around the headreceiving part 5.

As can be seen in FIGS. 1, 3, and 16 a to 16 b the head receiving part5, the locking ring 6, and the cap 8 are configured to allow a placementof the cap 8 onto or over the locking ring 6 with inserted rod 7 in afirst position, in which the legs 87 a, 87 b extend into the cutouts 53a, 53 b of the head receiving part 5. The cap 8 and the head receivingpart 5 are further configured to allow a rotation of the cap 8 to asecond position in which the undercut portion 84 of the cap 8 engagesthe undercut portion 51 c of the head receiving part 5. In the secondposition, the cap 8 is prevented from being pulled off of the headreceiving part 5 in a direction along the central axis C of the headreceiving part 5.

The head receiving part 5, the locking ring 6, the cap 8, and thelocking element 9, as well as the bone anchoring element 1, are made ofbio-compatible materials, for example, of titanium or stainless steel,of bio-compatible alloys, such as nickel-titanium alloys, for example,Nitinol, or of a bio-compatible plastic material, such as, for example,polyetheretherketone (PEEK). The parts can be made of the same or ofdifferent materials.

Referring to FIGS. 17 to 22, steps of mounting and use of the polyaxialbone anchoring device will be explained. As shown in FIG. 17, thelocking ring 6 is mounted from the second end 5 b to the head receivingpart 5 such that, as shown in FIG. 18, the projections 63 for receivingthe rod 7 extend upwards from the first end 5 a of the head receivingpart 5. An orientation of the locking ring 6 relative to the headreceiving part 5 is such that the projections 63 are aligned with thecylinder-segment shaped recess 52 of the head receiving part 5. The rimportion 51 at the positions of the ends of the recess 52 may besupported by the support surfaces 65 of the locking ring 6. The headreceiving part 5 and the locking ring 6 may be delivered in apre-assembled manner.

In a second step, shown in FIG. 18, the bone anchoring element 1, with asuitable shank 2 for a specific clinical application, is mounted fromthe second end 5 b to the assembly formed by the head receiving part 5and the locking ring 6. The locking ring 6 may be in an uppermostposition. The head 3 is introduced into the internal hollow section 56of the head receiving part 5. This is facilitated by the head receivingpart 5 being flexible.

At this stage, the modularity of the bone anchoring device allowscombining of a bone anchoring element with a specific shank with thehead receiving part 5 during or before surgery. The polyaxial boneanchoring device, thus assembled, is then inserted into a bone or avertebra. In an alternative way of use, the bone anchoring element isfirst inserted into the bone or into the vertebra, and thereafter, theassembly including the head receiving part 5 and locking ring 6 ismounted to the head after implantation of the screw.

Then, as shown in FIG. 19, the locking ring 6 is shifted downwards, sothat the locking ring 6 compresses the head receiving part 5. Here, thehead 3 can be held in a preliminary angular position, and the lockingring 6 may also be held in this position, for example, by frictionalforces acting between the head receiving part 5 and the head 3 on theone hand and between the locking ring 6 and the head receiving part 5 onthe other hand.

In a next step, as shown in FIG. 20, the rod 7 is inserted into therecesses 64 of the projections 63. Because the recesses 64 have circularsegment shapes including more than a largest diameter of the circle, therod 7 can be caught or held in the recesses 64, so that the rod 7 ispreliminarily held in place therein.

In a next step, as shown in FIG. 21, the cap 8 is placed onto theassembly. The locking element 9 may be pre-assembled with the cap 8. Ina first position, the legs 87 a, 87 b extend along or are aligned withthe cutouts 53 a, 53 b. By means of this, the legs 87 a, 87 b extendinto the space between the projections 63 of the locking ring and therim portions 51 a, 51 b of the head receiving part 5. Next, as shown inFIG. 22, the cap 8 is rotated so that the undercut portions 84 engagethe undercut portions 51 c at the rim portions 51 a, 51 b of the headreceiving part 5. In this second position, the cap 8 is prevented frombeing pulled away from the head receiving part 5 in an axial direction.Then, the locking element 9 is tightened. The lower surface of thelocking element 9 contacts the rod 7, and the rod 7 is pressed into therecesses 64 of the projections 63 of the locking ring 6. The forceacting onto the rod 7 is thereby transferred to the locking ring 6, andthe locking ring 6 is shifted downwards until it firmly compresses thehead receiving part 5 and locks the head 3. Hence, the head 3 and therod 7 are locked simultaneously relative to the rest of the boneanchoring device.

A second embodiment of a polyaxial bone anchoring device will bedescribed with reference to FIGS. 23 to 36 b. Parts and portions thatare identical or similar to the parts and portions of the firstembodiment are designated with the same reference numerals, and thedescriptions thereof shall not be repeated. The bone anchoring deviceaccording to the second embodiment differs from the bone anchoringdevice according to the first embodiment in the design of the headreceiving part and the cap.

As shown in particular in FIGS. 23 to 28, the head receiving part 5′does not include a rod guiding recess. Instead, the head receiving part5′ includes a first cylindrical portion 50′ and an outwardly extendingrim including two opposite radially and circumferentially extendingbrackets 51 a″, 51 b′, with upstanding rims having an undercut portion51 c′. Each bracket 51 a″, 51 b′ has a flattened side so that oppositeflat surfaces 52 a′, 52 b′ are formed at an outer circumference of thecylindrical portion 50′. Between the flat surfaces 52 a′, 52 b′ and thebrackets 51 a′, 51 b′, there may also be cylindrical surfaces.Furthermore, the head receiving part 5′ includes at the first end 5 a anupstanding circular rim 54 with a diameter smaller than an outerdiameter of the cylindrical portion 50′. At an outside of the rim 54,there is an inclined surface 54 a with an incline opposite to theincline of the undercut portion 51 c′ so that surface 54 a formstogether with the undercut portion 51 c′ a substantially dovetail-shapedgroove 5 d, as can be seen in particular in FIG. 28. Meanwhile, aportion of rim 54 not aligned with undercut portion 51 c′ may not havethe inclined surface 54 a, and may instead be cylindrical, for example,to allow the legs of the cap 8′ to be inserted from above. The lowerportion of the head receiving part 5′ is identical or similar to that ofthe head receiving part 5 of the first embodiment.

Referring to FIGS. 29 to 34, the cap 8′ according to the secondembodiment differs from the cap 8 according to the first embodiment inthat the cap 8′ has a coaxial bore 82′ that has a diameter only slightlylarger than a diameter of the threaded through hole 81′. Cuboid orrectangular shaped recesses 86 a′, 86 b′ define longitudinally extendinglegs 87 a′, 87 b′ of the cap 8′. At a second end 8 b, the cap 8′includes dovetail-shaped portions 85′ that cooperate with thedovetail-shaped grooves 5 d at the head receiving part 5′. The polyaxialbone anchoring device according to the second embodiment may have aneven more reduced height than the first embodiment.

Hence, when the cap 8′ is placed on the assembly including anchoringelement 1, head receiving part 5′, and locking ring 6, in a firstposition, the legs 87 a′, 87 b′ extend along cylindrical portions of thehead receiving part. Then, as shown in FIGS. 35, 36 a, and 36 b, the cap8′ can be rotated, thereby engaging the dovetail-shaped rims 85′ withthe dovetail-shaped grooves 5 d at the head receiving part 5′, so thatthe cap 8′ is connected to the head receiving part 5′, and the rod 7 issecured against removal. The dovetail shapes prevent pulling off of thecap 8′ in an axial direction relative to the head receiving part 5′.Then, the locking element 9 can be tightened to fix the whole assembly.

In FIGS. 37 a and 37 b, a head receiving part of a further alternateembodiment is shown. In FIGS. 37 a and 37 b, a head receiving part 5″ isshown with a configuration different from the head receiving part fromthe first embodiment. Namely, the rim portions 51 a and 51 b have adifferent configuration, which can be described as being on oppositeportions of the head receiving part 5″, as compared to the rim portionsof the head receiving part of the first embodiment.

In FIGS. 38 a to 38 c, a further alternate embodiment of a polyaxialbone anchoring device includes the head receiving part 5″ shown in FIGS.37 a and 37 b. The assembly of the bone anchoring device in FIGS. 38 ato 38 c is similar to that shown in FIGS. 20 to 22, with the exceptionthat in FIGS. 38 a to 38 c, the cap 8 and the locking element 9 aretightened in the same direction, whereas in FIGS. 20 to 22, the cap 8and the locking element 9 are tightened in opposite directions. Thealternate steps illustrated in FIGS. 38 a to 38 c may follow the stepshown in FIG. 19.

In FIG. 38 a, the rod 7 is inserted into the recesses 64 provided at theprojections 63. Because the recesses 64 have circular segment shapesincluding a largest diameter of the rod 7, the rod 7 can be caught orheld in the recesses 64, so that it is preliminarily held in placetherein.

In a next step, as shown in FIG. 38 b, the cap 8 is placed onto the restof the assembly. The locking element 9 may be pre-assembled with the cap8. In the first position, the legs 87 a, 87 b extend along or arealigned with the cutouts 53 a, 53 b, and thus extend into spaces betweenthe projections 63 of the locking ring 6 and the rim portions 51 a, 51 bof the head receiving part 5″.

Next, as shown in FIG. 38 c, the cap 8 is rotated so that undercutportions 84 engage undercut portions 51 c at the rim portions 51 a, 51 bof the head receiving part 5″. In this second position, the cap 8 isprevented from being pulled away from the rest of the assembly in anaxial direction. Then, the locking element 9 is tightened in the samedirection as the cap 8. For example, both locking element 9 and cap 8may be rotated clockwise, or alternatively, both may be rotatedcounterclockwise, in order to be tightened or locked. The tightening ofboth the locking cap 8 and the locking element 9 in a same direction isenabled by the alternate arrangement of the cutouts 53 a, 53 b and therim portions 51 a, 51 b. Namely, the cutouts 53 a, 53 b are oriented tobe upstream of the rim portions 51 a, 51 b, with respect to thedirection of locking of both the cap 8 and the locking element 9.Because the cap 8 and the locking element 9 are tightened in the samerotational direction, the locking force of locking the assembly isincreased. In addition, with a same direction of locking, tightening ofthe locking element 9 will not result in inadvertent loosening of cap 8.

Upon tightening, the lower surface of locking element 9 contacts the rod7 and the rod 7 is pressed into the recesses 64 of the projections 63 ofthe locking ring 6. The force acting onto the rod 7 is transferred tothe locking ring 6, and the locking ring 6 is shifted downwards tofirmly compress the head receiving part 5″ and lock the head 3 therein.The head 3 and the rod 7 may be locked simultaneously upon fixing orlocking the assembly. When tightening the locking element 9, theconnection between the head receiving part 5″ and the cap 8 may also bereinforced.

It shall be understood that various modifications of the embodimentsshown are also possible. Any engagement structure of the cap and thehead receiving part that prevents pulling off of the cap when in anengaged position can be implemented. In particular, a size of rimportions or of dovetail grooves in a circumferential direction may bedifferent from the embodiments shown.

Other modifications are also conceivable. For example, theconfigurations of the locking ring and of the cooperating outer surfaceportion of the head receiving part can be designed in other ways. Forexample, an the inner surface of the locking ring can be tapered andcooperate with a tapered outer surface of the head receiving part. In afurther example, an outer surface portion of the head receiving part canbe convexly rounded, and an inner surface of the locking ring can bestraight or tapered. In some embodiments, the cooperating surfaces ofthe locking ring and the head receiving part can also be parallel, sothat the clamping of the head is achieved by an interference fit betweenthe locking ring and the head receiving part.

For the bone anchoring element, various bone anchoring elements can beused that differ with respect to their shank lengths, diameters, orthread forms. Some bone anchoring elements may have a through channelwith openings for introducing of drugs or bone cement. Also, hooks,nails, or any other anchoring elements can also be used.

The various rod receiving recesses can also be semi-circular,quarter-circular, or U-shaped, or can have various other shapes that areconfigured to accommodate a rod therein.

While the present invention has been described in connection withcertain exemplary embodiments, it is to be understood that the inventionis not limited to the disclosed embodiments, but is instead intended tocover various modifications and equivalent arrangements included withinthe spirit and scope of the appended claims, and equivalents thereof.

1. A polyaxial bone anchoring device comprising: a bone anchoringelement having a shank for anchoring to a bone and a head; a headreceiving part having a first end, an open second end, and a hollowinterior portion in communication with the open second end for receivingthe head therein, the head receiving part being flexible for clampingthe head; a locking ring configured to be mounted around the headreceiving part, the locking ring comprising a rod receiving portion; acap configured to be connected to the head receiving part, the caphaving a first end, a second end, and a central axis extending throughthe first and second ends of the cap; and a locking element configuredto extend from the cap to engage an inserted rod and to lock relativepositions of the bone anchoring element and inserted rod relative to thehead receiving part; wherein when the head is in the head receiving partand the locking ring is around the head receiving part, the head ispivotable in the head receiving part and can be locked at an anglerelative to the head receiving part by compressing the head receivingpart with the locking ring; and wherein the cap is rotatable relative tothe head receiving part between a first position in which the cap ismovable axially in a first direction away from the second end of thehead receiving part, and a second position to prevent movement of thecap in the first direction and to hold an inserted rod between the capand the head receiving part.
 2. The bone anchoring device of claim 1,wherein the head receiving part further comprises a portion adjacent tothe first end with an undercut for engagement by the cap.
 3. The boneanchoring device of claim 1, wherein the head receiving part furthercomprises two diametrically opposed radial projections for engagementwith the cap.
 4. The bone anchoring device of claim 3, wherein the headreceiving part has a portion arranged along a longitudinal axis forreceiving an inserted rod, and wherein the radial projections arearranged substantially at 30° to 60° relative to the longitudinal axis.5. (canceled)
 6. The bone anchoring device of claim 1, wherein aflexible region of the head receiving part has an outer surface with anouter diameter that increases towards the open second end.
 7. The boneanchoring device of claim 1, wherein a flexible region of the headreceiving part comprises a wall having a plurality of slits.
 8. The boneanchoring device of claim 1, wherein the head has a spherical outersurface portion, and wherein the hollow interior portion of the headreceiving part defines a spherical seat portion for the head.
 9. Thebone anchoring device of claim 1, wherein the head receiving part has athrough hole at the first end in communication with the hollow interiorportion, the through hole having a diameter smaller than a greatestdiameter of the head.
 10. The bone anchoring device of claim 1, whereinthe rod receiving portion of the locking ring comprises two projectionsdiametrically opposite to each other, the projections each having arecess for receiving and preliminarily holding a rod therein.
 11. Thebone anchoring device of claim 10, wherein the recess of each projectionhas a contour forming a circular segment defining more than asemicircle.
 12. The bone anchoring device of claim 1, wherein the cap issubstantially cylindrical and has two diametrically opposite recessesopen to the second end of the cap for a rod to pass through.
 13. Thebone anchoring device of claim 1, wherein the cap has a threaded throughhole, and wherein the locking element is a set screw configured to bearranged in the through hole.
 14. The bone anchoring device of claim 1,wherein the cap has an undercut portion for the engagement with the headreceiving part.
 15. (canceled)
 16. The bone anchoring device of claim 1,wherein the head receiving part has a rod guiding recess at the firstend.
 17. The bone anchoring device of claim 1, wherein a direction ofrotation of the cap from the first position to the second positionrelative to the head receiving part is the same as a direction ofrotation for advancing the locking element relative to the cap to lockthe bone anchoring device.
 18. A method of coupling a rod to a bone viaa polyaxial bone anchoring device, the bone anchoring device comprisinga bone anchoring element having a shank for anchoring to a bone and ahead, a head receiving part having a first end, an open second end, anda hollow interior portion in communication with the open second end forreceiving the head therein, the head receiving part being flexible forclamping the head, a locking ring configured to be mounted around thehead receiving part, the locking ring comprising a rod receivingportion, a cap configured to be connected to the head receiving part,the cap having a first end, a second end, and a central axis extendingthrough the first and second ends of the cap, and a locking element, themethod comprising: inserting the shank of the bone anchoring elementinto a bone or vertebra; connecting the head receiving part with thelocking ring mounted around the head receiving part to the boneanchoring element by inserting the head of the bone anchoring elementinto the hollow interior portion via the second end of the headreceiving part; rotating or pivoting the head receiving part and thelocking ring relative to the bone anchoring element; connecting a rod tothe rod receiving portion of the locking ring; connecting the cap to thehead receiving portion with the rod held therebetween by rotating thecap relative to the head receiving part from a first position in whichthe cap is movable axially in the first direction away from the secondend of the head receiving part to a second position to prevent movementof the cap in the first direction; advancing the locking element throughthe cap to engage the rod and to advance the rod and locking ringtowards the second end of the head receiving part to compress the headreceiving part and to lock relative positions of the rod and the boneanchoring element relative to the head receiving part.
 19. The method ofclaim 18 wherein the shank is inserted into a bone or vertebra prior toconnecting the head receiving part and the locking ring to the boneanchoring element.
 20. The method of claim 18, wherein the shank isinserted into a bone or vertebra after connecting the head receivingpart and the locking ring to the bone anchoring element.
 21. The methodof claim 18, wherein the locking ring is mounted around the headreceiving part from the second end of the head receiving part.
 22. Themethod of claim 18, further comprising shifting the locking ring towardsthe second end of the head receiving part prior to connecting the rod tothe locking ring to temporarily hold a position of the head receivingpart and the locking ring relative to the bone anchoring element.